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A 73-year-old uncircumcised man presents with a burning, solitary, well-demarcated, red-brown, shiny plaque on the glans. A fungal culture is negative, and there are no other abnormalities of mucous membranes. The most likely diagnosis is:

A. Lichen planus

B. Irritant contact dermatitis

C. Zoon's vulvitis

D. HSIL (PIN)

C. This patient exhibits the characteristic appearance of plasma cell mucositis or Zoon's balanitis. A well-demarcated plaque of irritant contact dermatitis is unlikely in an uncircumcised man, and lichen planus may have this morphology but generally is not a solitary plaque without oral disease. A biopsy is indicated to rule out PIN, but it is only solitary in a setting of lichen planus or lichen sclerosus, which are not described here.

An 81-year-old woman has lichen sclerosus which is improving with clobetasol ointment. However, her anterior vulva remains irritated and raw. Management of her symptoms will improve with:

A. Application of topical benzocaine (Vagisil) for pain control

B. Washing the vulva after each urination and drying with a hair dryer

C. Management of incontinence

D. Changing laundry detergent and double rinsing clothes

C. Urinary incontinence is an extremely common cause of irritant contact dermatitis in the elderly. Contact dermatitis is a common secondary phenomenon in the management of vulvar symptoms. A common cause is the application of medications, and benzocaine is a prominent cause of allergic contact dermatitis and should be avoided. Laundry detergent is not a usual cause of contact dermatitis, and would produce dermatitis of other areas that touch clothing. Over washing and incontinence are typical irritants in older women.

Appropriate choices to treat inverse genital psoriasis include:

A. Topical tar

B. Salicylic acid shampoos for scalp psoriasis

C. Topical corticosteroid ointment

D. Ultraviolet light

C. Genital psoriasis usually responds well to topical corticosteroids and is first-line therapy. The ointment vehicle is preferred as creams often burn with application. Frequent reevaluation and prompt decrease in the potency of the topical corticosteroid are important in preventing steroid atrophy. Topical tar and salicylic acid are too irritating for genital skin. Ultraviolet light is useful for psoriasis in general, but is impractical in the genital area, and ultraviolet light is known to increase the risk of cutaneous squamous cell carcinoma, so is best avoided.

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